Chapter 13
Building an Evidence-Based Nursing
Practice
Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
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Evidence-Based Practice
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Conscientious integration of best research
evidence with clinical expertise and patient
values and needs in delivery of quality costeffective health care
Has a broader focus than research use
Goal is implementation of quality costeffective care to promote positive outcomes
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Barriers to EBP
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Practical
Conceptual
May create a “cookbook” approach to care
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Benefits to EBP
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Improved patient outcomes for patients,
providers, and agencies
Leads to best treatment (Gold Standard) plan
An integral part of the Magnet Status process
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Evidence-Based Sources
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Systematic reviews
Meta-analyses
Integrative reviews
Metasummaries
Metasyntheses
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Developing Evidence-Based Practice
for Nursing
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Findings from a study are different from
research evidence.
Research evidence is a synthesis of quality,
relevant studies to form a body of empirical
knowledge for selected area of practice.
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Synthesis of Research Findings
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Knowledge comes from quantitative,
qualitative, and outcomes research.
Content clustering: integration of findings
from scientifically sound research to
determine what is currently known or not
known
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Accomplished through:
• Integrative reviews
• Systematic reviews
• Meta-analyses, metasummaries, metasyntheses
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Integrative Reviews
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Identifies, analyzes, and synthesizes results
from independent quantitative and qualitative
studies to determine current knowledge
Includes multiple types of research designs
and literature types
A complicated review, but gives breadth and
depth to conclusions
Annual Review of Nursing Research
publishes integrative reviews.
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Qualitative Research Contributions to
Integrative Reviews
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Identifies and refines questions and
outcomes
Identifies types of participants and
interventions
Augments and provides data for research
synthesis
Highlights inadequacies in methods
Explains findings and interpretation of
findings
Helps make recommendations
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Systematic Reviews of Research
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A narrowly focused synthesis of research
findings from quantitative studies
Looks at studies of similar methodology
Has same standards of clarity, rigor, and
replication as primary research studies
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Steps in Systematic Reviews
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Formulate purpose and identify scope.
Develop specific questions or hypotheses.
Establish criteria for inclusion/exclusion of
studies.
Conduct extensive literature search of all
sources.
(Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)
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Steps in Systematic Reviews (cont’d)
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Develop questionnaire and contact authors to
gather data.
Critique studies for scientific merit and data
analysis.
Analyze and interpret data.
Report the review.
(Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)
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Meta-analyses of the Research
Literature
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Statistically pools results from previous
studies into single quantitative analysis
Allows for application of scientific criteria
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For example, sample size, level of significance,
variables
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Results of Meta-analysis
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A large, diverse sample that is more
representative of target population
Determination of overall significance of
probability of pooled data
Indication of the efficacy of the intervention
from the average effect size determined from
several quality studies
Strength of relationship between variables
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Metasummaries in Qualitative
Research
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Definition: a synthesis of multiple primary
qualitative studies to produce a narrative
about a selected phenomenon
Expands our knowledge base
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Metasynthesis of Qualitative
Research
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Synthesizes qualitative research with a critical
analysis of primary studies and synthesis of
findings into a new theory
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Best Evidence for Use in Practice
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The strength of the evidence is on a
continuum from high-quality results to lowerquality results.
Evidence-based guidelines are essential in
developing evidence-based practice for
nursing.
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Continuum of Strength of Research
Evidence
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Strength of Evidence
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Strongest evidence
1.
2.
3.
Meta-analysis
Integrative reviews
Experimental studies
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Weakest evidence
1.
2.
3.
4.
Descriptive surveys
Qualitative studies
Correlational studies
Quasi-experimental
studies
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Stetler Model of Research Utilization
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Phase I: Preparation
Phase II: Validation
Phase III: Comparative Evaluation/Decision
Making
Phase IV: Translation/Application
Phase V: Evaluation
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Iowa Model of Evidence-Based
Practice
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Provides direction for development of
evidence-based practice in an agency
Looks at triggers for change, such as:
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Risk management data
Financial data
Organizational standards
Philosophy of care
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Iowa Model of Evidence-Based
Practice (cont’d)
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Application of the Iowa Model
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What are effective strategies for
implementation?
What are outcomes from using the research
findings?
Do the data support the change?
Is the proposed change an agency priority?
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Scientific Merit Critique
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According to the Iowa model, research should
be examined for:
Conceptualization and internal consistency of the
study
2. Methodological rigor of the design, sample
methods, data, and analysis
3. Generalizability of the findings
4. Number of replications
1.
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Determining Agency Compatibility
with the Change in Practice
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Who needs to approve the change in the
agency?
What steps are needed to get the change
approved in the institution?
Do physicians support the change?
Do nurses support the change?
Who are the leaders and will they support the
change?
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Instituting the Change in Practice
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Will the implementation take a long time?
What support is needed to make the change?
Are there barriers to instituting change in the
agency?
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Utilization Barriers
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Administration barriers
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Research not valued
Limited change in agency or change not based on
research
Limited resources to make research-based
change
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Utilization Barriers (cont’d)
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Clinician barriers
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Do not read research reports
Lack education about research process
Do not believe research findings
Do not know how to implement findings
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Monitoring Outcomes
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After the change is effected, the outcomes
must be monitored for effectiveness.
Change should be documented regarding
improved quality of care, decreased costs,
saved nursing time, and improved access to
care.
Feedback is needed.
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The Cochran Collaboration
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P – Population or participant of interest
I – Intervention needed for practice
C – Comparison of interventions to determine
best practice
O – Outcomes needed for practice
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Development of Evidence-Based
Guidelines
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AHRQ helps with guidelines through
development of an expert panel.
The group designates the scope of the
guidelines.
They synthesize the findings to develop
recommendations for practice.
Guidelines developed are presented at
meetings and published.
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Examples of AHRQ Practice
Guidelines
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Pain management
Decubiti prediction/prevention
Cataract treatment in adults
Depression treatment
Screening, diagnosis, management of sickle
cell disease in newborns and infants
Otitis media treatment in children
Availability of cardiac rehabilitation services
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Access to Evidence-Based Guidelines
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Agency for Healthcare Research and Quality
(AHRQ)
National Guideline Clearinghouse (NGC)
Academic Center for Evidence-Based
Nursing
American College of Physicians
American Academy of Pediatrics
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Implementing a Model of EvidenceBased Practice
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Identify practice problem.
Search for best research evidence.
Determine quality of guideline by assessing:
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Authors
Significance of problem
Strength of evidence
Link to national standards
Cost-effectiveness of guideline
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Translational Research
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An evolving concept defined by the NIH as
the translation of basic scientific discoveries
into practical application
Encouraged by nursing and medicine to
increase the implementation of evidencebased interventions in practice and determine
if these interventions are effective
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